The Quality Improvement Challenge. Richard J. Banchs
expectation that the burden of operational improvement should be left to staff and hospital administration, a tenet described by Kornacki as “The Physician Compact” (Kornacki 2012): “The Physician Compact is an implicit psychological contract that defines the actions physicians believe are expected of them and the response they expect in return from their employers.”
According to this compact, physicians believe their role is to treat patients, provide quality care (as defined by the physician), advance research, and support medical education. In return, they expect to be given clinical autonomy, protection from market forces, and the resources needed to resolve operational problems. In contrast, hospitals and healthcare organization need standardization, improved efficiencies, lower costs, and physician engagement in operational challenges. There is an internal incongruence between physicians’ expectations and hospital needs that results in resentment, misunderstandings, and a lack of physician engagement in operational improvement (Kornacki 2015). Efficiency and standardization are often perceived by physicians as a restriction to their ability to integrate their knowledge, experience, and assessment skills in their clinical practice. Ironically, it is often the physicians who initially identify processes that are dysfunctional and are open to becoming engaged in “their project” when there is adequate facilitation and coordination by another staff member.
REFERENCES
1 1. Berwick D. (2016). Era 3 for medicine and health care. JAMA 315: 13.
2 2. Christensen Cl. (2009). The Innovator’s Prescription. McGraw Hill.
3 3. Institute of Medicine. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. National Academy Press, March.
4 4. Kohn LT. (2000). To Err Is Human: Building a Safer Health System. Institute of Medicine Committee on Quality of Health Care in America. National Academies Press.
5 5. Kornacki MJ. (2015). A New Compact: Aligning Physicians and Organization Expectations to Transform Patient Care. Health Administration Press.
6 6. Kornacki MJ. (2012). Leading Physicians through Change. ACPE.
7 7. Leape L. (2009). Transforming healthcare: a safety imperative. Qual Saf Health Care 18: 424–428.
8 8. Nicolay CR. (2012). Systematic Review of the application of quality improvement methodologies from the manufacturing industry to surgical healthcare. British Journal of Surgery 99: 324–335.
9 9. Porter M. (2016). The Future Perioperative Physician: Leaders in Value Based Health Care Delivery. Keynote Speaker. ASA Annual Meeting. Chicago.
10 10. Wyman O. (2014). The Patient to Consumer Revolution. How High Tech, Transparent Marketplaces, and Consumer Power Are Transforming US Healthcare. Health and Life Sciences.
CHAPTER 2 We Need to Improve the Way We Improve
WHAT’S THE GOAL OF A QI PROJECT?
First, Define Quality
The goal of healthcare is to provide quality care. The traditional quality paradigm was centered on the provider’s point of view and the notion that quality care was effective care. But expectations have changed, and the paradigm has evolved to one centered on the patient’s perspective, which includes not only the treatment but the healthcare experience. Quality is no longer just “effective” care. Quality is now defined as much by the therapeutic intervention as by how we meet patients’ expectations. In 2001, the Institute of Medicine defined quality along six dimensions: effective, efficient, timely, safe, patient‐centered, and equitable (IOM 2001). In this new paradigm, assessing quality requires us to evaluate “what” was provided i.e. effective and safe care, as well as “how” it was provided, i.e. efficient, timely, culturally sensitive, and equitable care (see Figure 2‐1).
FIGURE 2‐1 The new quality paradigm.
Patients remain at the center of our delivery system because they are the reason healthcare organizations exist. Clinicians provide care to patients and expert services to other providers. Leaders and ancillary staff support the providers’ clinical practice within a complex, multidimensional system. Together, their efforts yield the patient’s outcomes and experiences. Our aim is to provide care that is effective in addressing the disease process, and is delivered in an efficient, timely, safe, patient‐centered, and equitable manner. This paradigm shift has redefined not only quality but the role of the healthcare provider. It is no longer sufficient to provide treatment for a patient’s clinical condition; we must also improve the quality of the healthcare delivery system to address patients’ expectations of the holistic care experience.
Then, Define Improvement
Improving the quality care for our patients cannot be achieved just by increasing resources and cost in a wasteful manner. Improvement is centered on value. There are numerous definitions of value. For now, let’s consider value as the outcomes achieved (therapeutic intervention + patient experience), divided by resources used in achieving the outcomes. To improve, we need to focus on achieving quality care while optimizing the quantity of resources such as time, personnel, and money consumed in working to achieve it (see Figure 2‐2).
FIGURE 2‐2 The goal of improvement.
Quotable quote: “The biggest room is the room for improvement.” Chinese proverb
A BETTER IMPROVEMENT STRATEGY
The identified barriers and characteristics of currently used improvement practices have contributed in part to failed improvement projects and frustrated healthcare leaders and clinicians. Healthcare is a complex and dynamic system, and the pressure of the current healthcare marketplace requires “organic and continuous improvement initiated and sustained at all levels and areas of the organization” (Pennington 2017). We need to move beyond the small, dedicated teams of subject‐matter experts that lead and support specific priority initiatives. Healthcare professionals throughout the organization need to acquire the knowledge, behaviors, and skills that define competency in quality improvement work, and become the drivers of the healthcare transformation. Improvement needs to be embedded in the DNA of healthcare organizations. Rather than imposed from the “top‐down,” improvement must come from the “bottom‐up,” inspired by a vision that enlists professionals in a common cause. “Top‐down” and “bottom‐up” approaches have to converge.
Improvement needs a problem‐solving approach that engages frontline professionals in creating solutions through a focus on the needs and values of the patients the solutions will serve, and the staff and providers who will deliver them.
Frontline professionals will need to be involved in all aspects of QI. Their engagement is critical to develop, revise, and monitor the performance of core care processes. Engagement of the frontline professionals depends on three enablers:
1 Engaged leadership. Leaders need to be actively engaged in creating an improvement agenda and providing the needed resources. Leaders are key in assuring the